GSTF Journal of Nusing and Healthcare (JNHC) Vol.3 No.
1, November 2015
GSTF Journal of Nusing and Health Care (JNHC) Vol.3 No.1, November 2015
Nurse Practice Environment and Quality of
Care in a Multigenerational Workforce
Doruthy Velasco Ferrer and Alita R. Conde
Abstract In recent years, the nurse practice environment
included nurses from multigenerational [1, 2, 3, 4] presenting
organizational hurdles as they collaborate on nursing teams [5,
6] that affected the quality of care they render. Thus, the present
study was conducted to ascertain the relationship of nurse
practice environment (NPE) and quality of care (QoC) in a
multigenerational workforce. The Practice Environment Scale
of the Nursing Work Index (PES-NWI; Lake, 2002) and Karen-
Personnel Instrument (Lindgren & Andersson, 2010) were
employed to measure the NPE and QoC, respectively. Data from
randomly selected staff nurses (N=213) from two (2) private
tertiary hospitals in Metro Manila were analyzed using Multiple
Linear Regression (MLR). Results indicated that
multigenerational workforce does not influence nurse practice
environment and quality of care (=0.004; p>0.05).
Nonetheless, findings of this study could expectedly yield
valuable insights that would assist nursing leaders to further
examine the nurse practice environment so that nurses could
function at the highest scope of clinical practice.
Keywords- nurse practice environment, quality of care,
multigenerational workforce, and generational cohorts
I. INTRODUCTION
In recent years, increasing diversity in the nursing
practice environment has challenged numerous healthcare
organizations in handling nurses from different
generational cohorts [1, 2, 3, 4, 7, 8, 9]. Hence, it is of
paramount significance to recognize the effect of
generational differences in creating a peaceful healthcare
milieu that promotes a higher quality of care. Currently,
nurses constitute the largest population of the healthcare
workforce and at the same time are faced with problems
related to workforce predicaments. However, when
handled well, those gaps can lead to a favorable outcome
that may create a healthy work environment [10, 11] and a
higher quality of care.
There is a paucity of information about the
relationship of nurse practice environment and quality of
care in the Philippines. Hence, it would be interesting to
look into the dynamics of nurse practice environment in
relation to quality of care in a Philippine setting.
DOI: 10.5176/2345-718X_3.1.102
The Author(s) 2015. This article is published with open access by the GSTF
138
Capitalizing on the power of a multiple linear regression,
this paper sought to ascertain the relationship of nurse
practice environment and quality of care in a
multigenerational workforce in two private tertiary
hospitals in Metro Manila. Results of the study are hoped
to generate valuable insights and implications that would
assist nursing leaders to scrutinize and improve if
necessary the nurse practice environment so that nurses
from each cohort could function at the highest scope of
clinical practice.
A. Generational Cohorts in the Workplace
Several scholars have defined generational cohorts as
groups of people, who share uniform birth years, historical
events, and personality [12, 9, 1, 5].
In recent years, nursing workforce has three leading
and apparent generational cohorts that adopt the dates as
Baby Boomers (born between 1946 and 1965), Generation
X (born between 1966 and 1980), and Generation Y, also
called Millenials (born between 1980 and 2000). The
literature suggests that every generation depicts distinctive
values and beliefs primarily due to their explicit
generational experiences [1]. Work values are likely to
have great impact on employees commitment to work.
Understanding their values is of paramount necessity
because the attitude toward work is affected by the degree
to which employees values their job.
It was hypothesized that generational diversity existed
due to environmental influence to early human
socialization [9]. These were influences that have
significant effect on personality development that once
developed they become deeply rooted to ones personality
into adulthood. As every generation comes of age, they are
conveyed to foster specific traits that make them unique
from those generations that are ahead and supersede them.
Thus, the first hypothesis is proposed:
Ha1a: The presence of multigenerational workforce
positively impacts nurse practice environment.
 GSTF Journal of Nusing and Healthcare (JNHC) Vol.3 No.1, November 2015
GSTF Journal of Nusing and Health Care (JNHC) Vol.3 No.1, November 2015
B. Nurse Practice Environment
In the context of nursing, nurse practice environment
has been defined as any locations where professional
nursing practices can either support or constrain it [13, 14].
It also subsumes understanding of nursing competence
[15] and increases circumstances for autonomous decision
making [16]. Both the workplace and all aspects embodied
within it comprise the nurse practice environment [17]
Following are the subscales comprising nurse practice
environment [13]:
Nurse participation in hospital affairs. Regarded
to be one of the powerful wings of healthcare system,
nurses have an essential role in development and progress
of health services [18]. Moreover, involvement in hospital
policy decisions, and nursing committees can increase
nursing satisfaction and role effectiveness.
Nursing foundations for quality of care. This
subscale is reflected by whether hospitals provide
preceptor system, active in-service, and continuing
education programs for nurse self-development [19].
Continuing professional education, on the other hand, is a
tool for quality service delivery that enhances the quality
of care the nurses provide [20].
Nurse manager ability, leadership, and support
for nurses. As the workforce becomes progressively
multigenerational, organizations need to contemplate on
both the differences and similarities of needs of employees
from different generational cohorts for versatility in the
work environment. Furthermore, sensibility on the
influence of the nurse practice environment on job
satisfaction of nurses and their retention within the
profession have become more intense and a major obstacle
in the health care industry [21]. Reference [15] cited in
[17], one eminent factor in the achievement of job
satisfaction in the nurse practice environment is the
supervisors ability to optimize environment for nursing
practice.
Staffing and resource adequacy. Hospital nurse
staffing is central to providing quality of nursing care.
Reference [22] stated that, RNs perception of having
adequate staffing and resources increased their own
assessment of patient safety by at least two and a half time
times to be exact.
Collegial nurse-physician relations. Nurse-
physician relationship is one of the most important
elements in the nurse practice environment. In recent
years, poor relationships of physicians and nurses in some
hospitals have caused serious problems within health care
settings. Decreased job satisfaction of nurses and other
conflicts in the practice environment are just one of those
ramifications. Disruptive behavior between physicians and
nurses not only affects teamwork in the workplace but also
The Author(s) 2015. This article is published with open access by the GSTF
139
hinders them to promote patient safety and ensure quality
care [23].
Given these points, the second hypothesis is
proposed:
Ha2: Nurse practice environment positively influences the
delivery processes of quality of care.
C. Quality of care
Definitions of quality of care are divided into two
aspects: whether the patient obtained the necessary care
and whether the rendered care is effective [24]. The quality
of care based from nurses perspectives that the study
aimed to bring forth includes the following dimensions:
Psychosocial relations, Commitment, Work satisfaction,
Openness/closeness, Competence development, and
Security/insecurity [25]. Several scholars have defined
quality of care as a degree of carrying out interventions
within standards of care that is safe and economical [26,
25].
Through the provision of high quality care, nurses
make a difference on human lives. And this quality health
care can only be perceived within the context of patients
culture. In like manner, creation of a workplace that takes
diversity into account will prevent multicultural conflicts
that hinder quality care and jeopardize patient safety [27].
Multicultural and multigenerational teams of nurses and
physicians are necessary to guarantee that the care being
provided is sensitive and meets the needs of culturally
diverse patients. One way or another, cultural, and
generational insensitivity can adversely affect patient
outcomes including the quality of care.
Thus, the following hypothesis is proposed:
Ha1b: The presence of multigenerational workforce will
lead to a higher quality of care.
D. The Hypothesized Model
Figure 1. The hypothesized relationship of nurse practice environment
and quality of care in a multigenerational workforce
In an ideal organization, nurses maintain a unique
role in identifying and guiding interventions central to
patient care. Emerging demographic shifts in the
workforce affects nurses performance in providing high
 GSTF Journal of Nusing and Healthcare (JNHC) Vol.3 No.1, November 2015
GSTF Journal of Nusing and Health Care (JNHC) Vol.3 No.1, November 2015
quality of care (Ha1b+). Through the creation of a working
atmosphere that supports and values nurses across
generations, a healthy nurse practice environment where
nurses from each cohort can function at the highest scope
of their clinical practice is achieved (Ha1a+).
This is well presented in the figure above showing
that nurse practice environment positively influences the
delivery processes of quality of care (Ha2+). Quality of
nursing care involves assessment of the structures,
processes, and outcomes. It also includes other dimensions
including psychosocial relations, commitment, job
satisfaction, openness/closeness, competence
development, and job security/insecurity.
The nurse practice environment in this context refers
to nursing workplace represented by its dimensions which
include nurse participation in hospital affairs; nursing
foundations for quality of care; nurse manager ability,
leadership, and support of nurses; staffing and resource
adequacy; and collegial nurse-physician relations. This
concept is supported by the findings in some literatures [30,
31, 32, 33] stating that modifications in the nurse practice
environment can lead to worthwhile outcomes in quality of
care [28].
II. THORETICAL BACKGROUND
This study is grounded on Donabedian Model a
three-dimensional model for measuring the quality of care
that was depicted by Donabedian IN 1980 who was known
to be the prime researcher in the field of quality care. He
defined Donabedians S P O Triad the structure, process,
and outcome [25]. Based from the Structure-Process-
Outcome paradigm, empirical evidence is presented stating
that the structure and process are represented by the nurse
practice environment that can lead to the outcome of
quality care [28]. Thus, it is likely that the setting or
structure in this study and all aspects embodied within it
may affect the delivery processes and care coordination
particularly of those nurses from Generations X and Y.
Consequently, this model postulates that to create a
positive nurse practice environment, it is important to
consider not only the differences and similarities of
employees across generations [29] but also the combined
effects of structure and process for the provision of high
quality care to patients. To sum it all, the quality of patient
care that is regarded as the outcome in this study, is
dependent on the performance of nurses from different
generations in nurse practice environment that represents
the structure and process.
The Author(s) 2015. This article is published with open access by the GSTF
140
III. METHODS
A. Sample
The study was conducted in the Philippines
particularly among 250 staff nurses from two private
tertiary hospitals in Metro Manila of whom only 213 have
participated during the actual implementation (85.20%).
Respondents were selected using stratified random
sampling. The effect size for this study was 0.195 (medium)
to 0.371 (large). The post hoc power cut off was 0.80, and
the study has achieved 0.97 to 1.0 thus indicating adequate
sample size and generalizability of the results [34].
B. Instrument
The study utilized a three-part questionnaire to
facilitate data collection. On the first part, respondents
robotfoto was utilized to collect demographic data from the
respondents in a standardized manner based from the
concepts of Generational Theory. It includes the
respondents age, birth year, gender, educational
background, job classification, area of assignment,
years/months in the current department or unit, and
years/months in the current hospital.
On the second part, the 31-item Practice Environment
Scale of the Nursing Work Index which was authored by
Lake in 2002 was utilized to measure the nurse practice
environment. It is the most frequently used survey-based
measure to determine the situation and status of nursing
practice environment [35] and manifested a Chronbach
alpha varying from 0.71 to 0.84 [13]. Respondents
expressed their level of agreement thru a 4-point Likert
scale where one implied strongly agree and four reflected
strongly disagree.
On the third part, the Karen Instruments (Karen-
Patient and Karen-Personnel) which was started by
Andersson in Sweden to measure quality of care and to
point out the need for improvement in quality of care. Out
of the two instruments, the Karen Personnel Instrument
was utilized in the study to gain insights on important
aspects of quality of care based from the perspectives of
nurses. Due to institutional policy and high patient
turnover, the patient-assessed quality of care was not
measured in the study. The 35 variables were grouped
based from Donabedians Triad. The manifested a
Cronbach alpha of 0.70 0.90 [25]. To measure variables,
the 5 point Likert scale as originally indicated in the
instrument was modified to an 8-point Likert Scale to
avoid social desirability bias [36]. The potential score for
quality of care ranges from 1 8 where scores of 1 4
indicated disagreement and 5 8 showed agreement.
C. Validity and Reliability
Preliminarily, four experts in the field of nursing
administration and health-related research who were not
 GSTF Journal of Nusing and Healthcare (JNHC) Vol.3 No.1, November 2015
GSTF Journal of Nusing and Health Care (JNHC) Vol.3 No.1, November 2015

part of the study have validated the questionnaire. To IV. RESULTS

establish the suitability to Philippine setting, the
questionnaire was pilot tested with 50 staff nurses in one A. Demographic Profile of the Respondents
of the two institutions that represent the various subgroups
within the target sample to determine the unforeseen The demographic profile of the respondents was
shown in Table I. Majority of the staff nurses were between
problems of the tool being used. Additionally, the pilot test
the ages of 21 25 years old (94.8%) who were born from
allowed modifications on the questionnaire to improve
1981 1992 belonging to Generation Y (94.4%) or known
clarity of the instructions and estimate the required time to
as Millenials. Reference [40] stated in his study that the
be completed. And to further test the reliability of the
instruments to be used, a Cronbachs alpha of 0.80 was nursing workforce in private hospitals in the Philippines
selected as the minimum acceptable reliability value. belonged to younger generations. According to the results,
the greatest portion of the workforce included nurses of less
Reliability coefficient results based from the pilot test
than 25 years of age. As expected, majority of the staff
were 0.952 for Practice Environment Scale of the Nursing
nurses were female, accounting 71.8% of the total number
Work Index (PES-NWI) and 0.886 for Karen-Personnel
of respondents, notwithstanding the fact that from the start
Instrument.
of 4th century, men have been identified to enter the
D. Ethical Consideration nursing profession [41, 42]. Looking into the highest
educational attainment of the respondents, 81.2% had a
A written approval from the Ethical Review Board of
bachelors degree in nursing. According to [32] cited in
the University of Santo Tomas was obtained prior to the
[43], educational level of nurses is a critical aspect in
implementation of the study. Ethical standards and
achieving a higher competence among nurses as it helps to
principles were observed accordingly during the conduct of
reduce the prevalence of mortality, morbidity and adverse
the study. Furthermore, informed consent was also obtained
effects. 55.8% of the respondents were assigned to work in
from the respondents to secure their willingness to engage
General Units of the hospital that included Medical-
in the study through a cover letter providing all the
surgical unit, Pediatric unit, Orthopedic unit, Maternity
necessary information, describing the study collectively, as
Unit, Pulmonary Unit, Ophthalmology unit, Geriatric unit,
well as indicating the rationale behind the respondents
etc. 45.1% of the respondents had been assigned in their
participation. The consent has also ensured that there would
current area of assignment for 1.1 3 years and 46.5%
be no inducement of authority on the part of the hospital
respectively were employed in the hospital for not more
administration on the participants. Respondents
than 3 years. These findings were also congruent to the
anonymity and confidentiality were also assured by using
study of [40] showing that there were higher turnover rates
number codes as pseudonyms. Furthermore, respondents
in the Philippine private hospitals.
were also informed of their right to refuse or to even
withdraw their participation even within the TABLE I. DEMOGRAPHIC PROFILE OF RESPONDENTS (N=213)
implementation phase of the study. Profile Freq. %
Age
E. Data Analysis 21 25 119 56.1
26 30 76 35.8
Data analyses were performed through the utilization 31 35 8 3.8
of Statistical Package for the Social Sciences version 21. 36 40 5 2.3
Frequency and percentage distribution were used to assess > 40 4 1.9
Gen. Cohort
the demographic data of the respondents. Application of
Gen X 8 3.8
multiple linear regression was utilized to ascertain the Gen Y 203 96.2
relationship [37, 38] between the multigenerational Gender
workforce, nurse practice environment, and quality of care. Male 60 28.2
Female 153 71.8
Analysis of variance (ANOVA) was used to validate the
Highest
goodness of fit of the regression model and F Test for Educational
significance of regression. Data were indicated as beta Attainment
standardized coefficients [39]. Statistical significance was BSN 173 81.2
MA/MS Units 35 16.4
set at p<0.05 if the p value is less than 0.05 but greater than
MA/MS Degree 4 1.9
0.01. If the p value, however, is less than 0.01 the level of PhD Units 1 .5
significance was set at p<0.01. Additionally, mean and Area of
standard deviation were also utilized for the analysis of Assignment
Special Units 94 44.1
descriptive statistics for the nurse practice environment and
General Units 119 55.8
quality of care. Years/months in
the current area
< 6mos 24 11.3
6 mos 1yr 51 23.9

The Author(s) 2015. This article is published with open access by the GSTF
141
 GSTF Journal of Nusing and Healthcare (JNHC) Vol.3 No.1, November 2015
GSTF Journal of Nusing and Health Care (JNHC) Vol.3 No.1, November 2015

1.1 3 yrs 96 45.1 the highest, respondents perceived positive nursing

3.1 5 yrs 22 10.3 foundations for quality of care (Mean=1.76; SD=0.43).
> 5 years 20 9.4
Years/months in Results also showed a positive nursing managers ability,
the hospital leadership, and support for nurses (Mean=1.84; SD=0.53),
< 6months 18 8.5 collegial nurse-physician relations (Mean=1.87;
6 months 1yr 48 22.5 SD=0.51), and nurse participation in hospital affairs
1.1 3 years 99 46.5
3.1 5 years 19 8.9 (Mean=1.96; SD=0.49). Conversely, the respondents
> 5 years 29 13.6 perceived a negative staffing and resource adequacy
Current Area of (Mean=2.20; SD=0.54). Taken collectively, however, the
Assignment means still revealed a positive nurse practice environment
Special Units 94 44.1
General Units 119 55.8 as perceived by the nurse respondents.
TABLE III. NURSE PRACTICE ENVIRONMENT SUBSCALES
B. Descriptive Statistics for Quality of Care Items Mean SD Rank

TABLE II. QUALITY OF NURSING CARE INDEX Nurses Participation in

Hospital Affairs 1.96 0.49 4
Items Mean SD Rank
Nursing Foundations for
Quality of Care 1.76 0.43 1
Nursing Manager's Ability,
Psychosocial Relations 80.73 12.86 3 Leadership, and Support for
Nurses 1.84 0.53 2
81.94 18.32 2 Staffing and Resource
Commitment
Adequacy 2.20 0.54 5
76.67 15.42 4 Collegial Nurse-Physician
Work Satisfaction
Relations 1.87 0.51 3
58.46 9.77 6
Openness/closeness
D. Regression Analysis
Competence 83.05 11.96 1
Development Table IV presents how well a regression model fits
75.32 12.63 5 between the dimensions of quality of care and the nurse
Job Security/insecurity
practice environment. The F-ratio in all models showed that
the predictors statistically significantly predicted criterion
variables. Thus, it can be concluded that the models fit the
The means for each statement were computed. Then data well.
for each subscale, the quality index was computed [25].
Consequently, the index would be over 100%. Thus the TABLE IV. MODEL FIT STATISTICS OF THE REGRESSION
higher index would be interpreted as higher quality of care. MODEL
In Table II, respondents perceived a very good level of Model Model Model Model Model Model 6
competence development (Mean=83.05; SD=11.96), 1 2 3 4 5
Criter Psych Commi Work Openn Compe Security
commitment (Mean=81.94; SD=18.32), and psychosocial ion o- tment satisfac ess/ tence
relations (Mean=80.73; SD=12.86). Furthermore, Varia social tion closene develo
respondents have reported a high level of work satisfaction ble relatio ss pment
(Mean=76.67; SD=15.42) and job security/insecurity ns
Predic Manag Founda Manag Collegi Founda Nurse
(Mean=75.32; SD=12.63). However, respondents tor/s ers tions ers al tions participa
openness/closeness was found to be less satisfactory ability for ability, nurse- for tion,
(Mean=58.46; SD=9.77). Based from the total quality quality adequa physici quality staffing
index of 76.028, the results have generally indicated that of care te ans of care adequac
staffing relation y
the respondents perceived a high quality of care in their , nurse s
current job wherein safety and clinical effectiveness could particip
be experienced by patients. ation

C. Descriptive Statistics for Nurse Practice R .457 .304 .521 .260 .327 .404
Environment R2 .209 .092 .271 .068 .107 .163
In Table III, ranking of nurse practice environment F 51.616 19.815 23.947 14.154 23.290 18.897
subscales were illustrated. Since the computed median was P-
.000 .002 .000 .000 .000 .000
Value
at 1.97, values less than 1.97 indicated agreement and
values more than 1.97 indicated disagreement. Ranked as

The Author(s) 2015. This article is published with open access by the GSTF
142
 GSTF Journal of Nusing and Healthcare (JNHC) Vol.3 No.1, November 2015
GSTF Journal of Nusing and Health Care (JNHC) Vol.3 No.1, November 2015
V. DISCUSSION
It is important to note that respondents in the current
study were composed mainly of nurses from Generation Y
(94.4%) who were born after 1980, which further made the
workforce considered young [40]. Known to be a
female-dominated profession [44, 45], 71.8% of the
respondents were expectedly females and only 28.2% were
males. Moreover, 45.1% of the respondents had been
assigned in their current area of assignment for 1 3 years
and 46.5% respectively were employed in the hospital for
not more than 3 years.
The results from the current study confirmed and also
refuted some of the research hypotheses. First of all,
regarding the effect of the nurse practice environment in the
quality of care, as expected, the dimensions of the practice
environment positively predicted the dimensions of quality
of care; and secondly, regarding the influence of the
multigenerational workforce in both of the nurse practice
environment, and quality of care. Each of these research
findings is discussed in turn, as follows:
Regarding the influence of nurse practice
environment in the quality of care provided by nurses, as
expected, the significant, positive relationship between
quality of care and the nurse practice environment was
confirmed. These results were largely consistent with the
previous findings of some research works [22, 46, 23, 47,
48, 20, 30]. Nurses who work in nursing units with a
healthy working atmosphere have displayed a higher
quality of care rendered to patients compared to those
nurses who are working in units where the essential factors
that make up a healthy nurse practice environment are not
met.
Findings of the study obtained through the utilization
of the Multiple Linear Regression (MLR) showed that
nurse managers ability, leadership and support for nurses
positively impacted psychosocial relations between nurses
(=0.457; p<0.01) and work satisfaction (=0.194;
p<0.01). One of the factors that have a great impact of the
effectiveness of nurses in an organization was the
leadership style of the respondents respective managers.
An appropriate approach of manager uplifted employees
morale that in turn enhanced positive psychosocial relations
and increased work satisfaction [18].
Nurse participation (=0.244; p<0.01) and adequate
staffing (=0.156; p<0.01) influenced further work
satisfaction. Reference [18] stress that nurses involvement
in an organizations affairs that include opportunities to
serve on hospital and nursing committees, internal
governance and policy decisions [46] have a considerable
effect on the effectiveness, thus increasing work
satisfaction. Additionally, adequate staffing allows nurses
to reduce errors related to patient care. Nurses are more
likely to report that certain tasks are left undone on shifts
The Author(s) 2015. This article is published with open access by the GSTF
143
with a higher ratio of patients per registered nurse. A higher
level of work satisfaction is perceived in an environment
with lower workloads where nurses can function at the
highest scope of clinical practice [49].
Good foundations for quality of care, on the other
hand, leads to higher levels of commitment (=0.304;
p<0.01), and competence development (=0.327; p<0.01).
One important aspect in the foundation for quality of care
includes a preceptor program offered to newly hired nurses
in an organization that helps them to enhance critical
thinking skills to be competent and skillful provider of a
safe patient care. Similarly, providing nurses opportunities
for continuing education programs [20] can enhance
competence development. An active staff development is
also a driving force that enhances not only nurses
competence but also their commitment to patient care.
Higher levels of nurse participation (=0.273;
p<0.01) and adequate staffing (=0.176; p<0.05) lead to a
higher job security. Nurses participation in hospital affairs
not only increases morale but also empowerment and
individual satisfaction among nurses [50]. Furthermore,
staffing and resource adequacy also protect nurses from
harm and problems related to patient care that may
jeopardize their profession. It is worth noting that working
in an environment with uncertainties and disempowerment
together with high demands from patients and organization
can threaten nurses job security and can eventually
contribute to nurses withdrawal from the organization.
Therefore, the higher the participation of nurses in hospital
affairs, the higher the respondents satisfaction and
intention to stay longer in the hospital, thus creating a
positive atmosphere in the workplace.
Finally, a positive collegial nurse-physician relation
positively impacts nurses openness/closeness (=0.260;
p<0.01). The result shows that open communication and
strong professional collaboration between nurses and
physicians when it comes to problem solving and decision-
making improves the quality of patient care.
Given these points, it can be concluded that nurse
practice environment has a positive significant influence in
the quality of care based from the nurses perspectives.
Regarding the influence of multigenerational cohort
in the nurse practice environment, and the quality of care,
contrary to several literatures which were discussed in
chapter two and the hypothesis stated in this study,
multigenerational workforce did not produce any
significant influence on the nurse practice environment, as
well as in the quality of care (= 0.004; p>0.05).
VI. CONCLUSION
This study attempted to ascertain the relationship of
nurse practice environment and quality of care in a
 GSTF Journal of Nusing and Healthcare (JNHC) Vol.3 No.1, November 2015
GSTF Journal of Nusing and Health Care (JNHC) Vol.3 No.1, November 2015
multigenerational workforce among staff nurses belonging
to Generation X and Generation Y from two tertiary
hospitals in Metro Manila.
Considering the dearth of literature on
multigenerational workforce and its influence on the
practice environment and quality of care, it is interesting to
know that multigenerational workforce does not influence
the two variables in this study. Despite changing
demographics in the workforce and an increased
complexity and changing needs of patients, this study has
successfully accounted the influence of nurse practice
environment and quality of care, particularly in a
developing country such as the Philippines.
Among the five dimensions of the nurse practice
environment, respondents posted a negative perception on
staffing and resource adequacy alone. It is well known in
the literature that variations in staffing levels have direct
impact on the delivery of patient care. Related studies were
also conducted in Asian countries like Taiwan and China
[35]. Setting standard minimum staffing levels has been a
widely discussed argument among international healthcare
organizations [51, 52] to address problems related to
staffing that may affect the quality of patient care.
However, problems arise due to its inflexibility that may
affect the workforce planning on the part of organizations
especially in developing countries where the status of
healthcare system is not as excellent as other healthcare
organizations in the US and Europe.
As one of the dimensions of nurse-perceived quality
of care, the nurses in this study perceived
openness/closeness as less satisfactory. This can also be
regarded as a result of negative staffing and resource
adequacy. Due to higher workloads, nurses find it difficult
to communicate properly and discuss matters related to
patient care while working on a specific nursing task to
meet the increasing demands of patients.
Since multigenerational workforce does not influence
nurse practice environment and quality of care, the study
suggests that strategies be developed that promote
retention. Another crucial suggestion is to consider hiring
nurses from older generation who have valuable insights,
knowledge, and personal experiences on providing quality
of care that they can impart to nurses from younger
generations.
Moreover, training and development on leadership
and management focusing on the significance of
participative management style in guiding a younger
workforce is an essential factor in improving managers
ability. This in turn promotes work satisfaction and higher
level of job security when nurses are involved in hospital
policy decisions, and nursing committees [18].
Consequently, highly satisfied and secured nurses will
function at the highest scope of their clinical practice thus
The Author(s) 2015. This article is published with open access by the GSTF
144
promoting safe practice and accordingly promote safe
practice and a higher quality of care. Furthermore, the study
also suggests on increasing competency training to enhance
nurses self-confidence and critical thinking skills that will
help them manage their time efficiently to get all the work
carried out well during their shift.
To further promote healthy working relations
between nurses and physicians, it will be profitable to
increase collaborative activities that include organizational-
wide socialization activities to promote enculturation `of
shared decision-making process [46]. A positive experience
of being a part of a well-functioning work group results to
a higher level of teamwork, positive working conditions,
and professional development between nurses and
physicians.
Since the assessment of quality of care based from
patients perspective was not included in the study, the
researcher suggests that future studies will include patients
perspectives in the assessment of quality of care to generate
additional findings that will create a deeper understanding
of the true picture of quality of care not only based from
nurses but also from patients.
REFERENCES
[1]. Brunetto, Y., Wharton, R. and Shacklock, K. Communication,
training, well-being, and commitment across nurse generations.
2011, Nursing Outlook, pp. 8-15.
[2]. Cahil, T. F. and Sedrak, M. Leading a Multigenerational Workforce:
Strategies for Attracting and Retaining Millennials. 2012, Frontiers
of Health Services Management, pp. 3-15.
[3]. De Meuse, K. P. and Mlodzik, K. J.A Second Look at Generational
Differences in the Workplace: Implications for HR and Talent
Management. 2010, People and Strategy, pp. 50-58.
[4]. Foley, V., Florence, M. and Yonge, O.Intergenerational conflict in
nursing preceptorship. 2012, Nurse Education Today, pp. 1003-
1007.
[5]. Salahuddin, M. M. Generational Differences Impact On Leadership
Style And Organizational Success. 2010, Journal of Diversity
Management, pp. 1-6.
[6]. Weingarten, Robin M. Four Generations, One Workplace: A Gen X-
Y Staff Nurse's View of Team Building in the Emergency
Department. 2009, Journal of Emergency Nursing, pp. 27-30.
[7]. McCready, V. General Issues in Supervision and Administration.
2011, ASHA Leader, pp. 12-15.
[8]. Nelson, S. A. Affective Commitment of Generational Cohorts of
Brazilian Nurses. 2012, International Journal of Manpower.
[9]. Srinivasan, V. Multigenerations in the Workforce: Building
collaboration. 2012, IIMB Management Review, pp. 48-66.
[10]. Gursoy, D., Qing, C. G. and Karadag, E.Generational differences in
work values and attitudes among frontline and. 2013, International
Journal of Hospitality Management, pp. 448-458.
 GSTF Journal of Nusing and Healthcare (JNHC) Vol.3 No.1, November 2015
GSTF Journal of Nusing and Health Care (JNHC) Vol.3 No.1, November 2015
[11]. Palumbo, M. V., et al. Retaining an Aging Nurse Workforce:
Perceptions of Human Resource Practices.2009, Nursing Economic,
pp. 221-227.
[12]. Silvia, N. A. Affective commitment of generational cohorts of
Brazilian nurses. 2012, International Journal of Manpower, pp. 804-
821.
[13]. Lake, E.T. Development of the Practice Environment Scale of the
Nursing Work Index. 2002, Research in Nursing and Health.
[14]. Kim, H., et al. The Nursing Practice Environment and Nurse-
Perceived Quality of Geriatric Care in Hospitals. 2009, Western
Journal of Nursing Reseach, pp. 480-495.
[15]. Morgan, J. and Lynn, M. Satisfaction in nursing in the context of
shortage. 2009, Journal of Nursing Management, pp. 401410.
[16]. Kramer, M., Brewer, B. and Maguire, P. Impact of Healthy Work
Environments on New Graduate Nurses' Environmental Reality
Shock. 2011, Western Journal of Nursing Research, pp. 348-383.
[17]. Moceri, J. T. Hispanic Nurses Experiences of Bias in the Workplace.
2013, Transcultural Nursing Society, pp. 15-22.
[18]. Hassankhani, H., et al. Management and Nurses Participation in
Hospital Affairs. 2013, International Research Journal of Applied
and Basic Sciences , pp. 1035-1037.
[19]. Shang, J., et al., et al. Nursing Practice Environment and Outcomes
for Oncology Nursing. 2012, Wolters Kluwer Health, pp. 1-7.
[20]. Nsemo, A., et al. Clinical nurses' perception of continuing
professional education as atool for qulaity service delivery in public
hospitals Calabar,Cross River State, Nigeria . 2013, Nurse
Education in Practice, pp. 328-334.
[21]. Norman, I. The Nursing Practice Environment. 2013, International
Journal of Nursing Studies, pp. 1577-1579.
[22]. Alenius, L., et al. Staffing and resource adequacy strongly related to
RN's assessment of patient safety: a national study of RNs working
in acute care hospitals in Sweden. 2013, BMJ Qality and Safety, pp.
1-10.
[23]. Brooks, A. T., Polis, N. and Phillips, E. The New Healthcare
Landscape: Disruptive Behaviors Influence Work Environment,
Safety, and Clinical Outcomes. 2014, pp. 39-44.
[24]. Claessen, Susanne J.J., et al. Measuring Relatives Perspectives on
the Quality of Palliative Care: The Consumer Quality Index
Palliative Care. 2013, J Pain Symptom Manage, p. 876.
[25]. Lindgren, M. and Andersson, Inger S. The Karen instruments for
measuring quality of nursing care: construct validity and internal
consistency. 2010, Oxford Journals, pp. 292-294.
[26]. Raven, J. H., et al. What is quality in maternal and neonatal health
care? 2011, Midwifery, pp. 677-679.
[27]. Jeffreys, M. Dynamics of Diversity: Becoming Better Nurses through
Diversity Awareness. 2008, pp. 36-41.
[28]. Siddiqui, N. Investing in human relations for healthy nursing
practice environment, nurse's job satisfaction and quality of nursing
care. 2013, American Journal of Nursing Research, pp. 10-19.
[29]. Beekman, T. Fill in the Generation Gap. 2011, Strategic Finance.
[30]. Van Bogaert, P., et al. The relationship between nurse practice
environment, nurse work characteristics, burnout and job outcome
and quality of nursing care: A cross-sectional survey. et al. 2013,
International Journal of Nursing Studies, pp. 1-11.
[31]. Sermeus, W., et al. Nurse forecasting in Europe (RN4CAST):
rationale, design and methodology. 2011, BioMed Central Nursing,
p. 10(1):6.
The Author(s) 2015. This article is published with open access by the GSTF
145
[32]. Aiken, L., et al. Patient safety, satisfaction, and quality of hospital
care:cross sectional surveys of nurses and patients in 12 countries
in Europe and the United States. 2012, British Medical Journal, p.
344.
[33]. Patrician, P. and Shang, J. and Lake, ET. Organizational
determinants of work outcomes and quality care ratings among
Army Medical Department registered nurses. 2010, Reseach in
Nursing & Health, pp. 99-110.
[34]. Soper, D. Statistics Calculators. Effect Size Calculator for Multiple
Regression. [Online] 2006.
http://www.danielsoper.com/statcalc3/calc.aspx?id=5.
[35]. Warshawsky, N. and Havens, D. Global Use of the Practice
Environment Scale of the Nursing Work Index. 2011, Nursing
Research, pp. 17-31.
[36]. Garland, R. The Mid-Point on a Rating Scale: Is it Desirble? 1991,
Marketing Bulletin, pp. 66-70.
[37]. Polit, D. E. and Beck, C. T. Nursing Research: Generating and
Assessing Evidence for Nursing Practice. s.l. : Lippincott Williams
& Wilkins, 2008.
[38]. Cho, Y. and Awbi, H.B. A study of the effect of heat source location
in a ventilated room using multiple regression analysis. 007,
Building and Environment, pp. 2072-2082.
[39]. De Guzman, A.B. Correlates of Geriatric Loneliness in Philippine
Nursing Homes: A Multiple Regression Model. 2012, Educational
Gerontology, pp. 563-575.
[40]. Perrin, M. E., et al., et al. Nurse migration and its implications for
Philippine hospitals. 2007, International Nursing Review, pp. 219-
226.
[41]. Evans, J. Men nurses: A historical and feminist perspective. 2004,
Journal of Advanced Nursing, pp. 321-328.
[42]. Eswee, A. and El Sayed, Y. The experience of Egyptian male student
nurses during attending maternity nursing clinical course. 2011,
Nurse Education in Practice, pp. 93-98.
[43]. Nilsson, J., et al. Developmenta nd validation of a new tool
measuring nurses self-reported professional competence - The
Nurse Professional Competence (NPC) Scale. 2014, Nurse
Education Today, pp. 574 - 580.
[44]. Morris, L. K. and Daniel, Larry G. Perceptions of a chilly climate:
Differences in traditional and non-traditional majors for women.
2008, Springer Science + Business Media, pp. 49:2562.
[45]. Bona, L., Kelly, A. and Jung, M. Exploring factors contributing to
women's nontraditional career aspirations. 2008, Psi Chi Journal of
Undergraduate Research, pp. 123-129.
[46]. Brandt, J., Edwards, D. and Sullivan, S. Empowering staff nurses
through unit-level shared governance: The nurse executive's role for
success. 2012, Nurse Leader, pp. 38-43.
[47] Cummings, G. et. al. Leadership styles and outcome patterns for the
nursing workforce and work environment: a systematic review.
2010, International Journal of Nursing Studies, pp. 363385.
[48]. Lin, H. Revisiting the relationship between nurse staffing and quality
of care in nursing homes: An instrumental variables approach. 2014,
Journal of Health Economics, pp. 13-24.
[49]. ' Ball, J., et al. Care left undone' during nursing shifts: associations
with workload and perceived quality of care. 2013, BMJ Quality and
Safety, pp. 1-10.
[50]. Benin, A., et al. Defining impact of a rapid response team:
qualitative study with nurses, physicians and hospital
administrators. 2012, BMJ Quality and Safety, pp. 391-398.
 GSTF Journal of Nusing and Healthcare (JNHC) Vol.3 No.1, November 2015
GSTF Journal of Nusing and Health Care (JNHC) Vol.3 No.1, November 2015

[51]. Mark, B., Harless, D.W. and Spetz, J. California's minimum-nurse-

staffing legislation and nurses' wages. 2009, Health Affairs, pp. 326-
234.
[52]. Sochalski, J., et al. Will mandated minimum nurse staffing ratios lead
to better patient outcomes? 2008, Medical Care, pp. 606-613.

AUTHORS PROFILE

Doruthy Velasco-Ferrer, R.N., M.A.N., obtained her Bachelor of

Science in Nursing at Manila Central University in 2006 and passed
the Nursing Licensure Examination on the same year. She has obtained
a Post Graduate Course in Occupational Health and Safety at the
College of Public Health, University of the Philippines - Manila, and
has worked as an Occupational Health Nurse, and a part time Allied
Health Instructor at the same time. Furthermore, she has also practiced
nursing in Drammen, Norway. In 2014, she has obtained Master of Arts
in Nursing, major in Nursing Administration at the University of Santo
Tomas, Manila, Philippines. She is currently working as a Medical
Affairs Officer.

Dr. Alita Ramos-Conde, R.N., M.A.N., obtained her Bachelor of

Science in Nursing, and Graduate Studies at the University of Santo
Tomas, Manila Philippines. She is an Associate Professor at the
University of Santo Tomas, College of Nursing, and a Professorial
Lecturer at the Graduate School, University of Santo Tomas.

The Author(s) 2015. This article is published with open access by the GSTF
146